Medicines optimisation in long-term pain.

‘#jargonbuster‘Medicines Optimisation’ means getting the medicines right for the individual. This may involve an alternative medicine, an alternative treatment or approach, and / or not taking medicines. The person’s experience, beliefs and what matters to them most should drive this decision, with clinicians providing guidance, advice and education on trusted sources of information, the evidence base and on safety’. (Steve Turner)

Patient safety incidents relating to the unsafe doses of opiates remain a major concern. People develop a ‘tolerance’ to opiate medicines, meaning that higher and higher doses may be needed to deliver the same effect. However this tolerance rapidly goes away when the opiates are stopped, so restarting at the old dose may be fatal.

‘A review of medicines-related safety incidents involving controlled drugs reported to the NRLS over 7 years found the risk of death with controlled drug incidents was significantly greater than with medication incidents generally (odds ratio 1.48, 95% CI 1.02 to 2.17). Incidents involving overdose of controlled drugs accounted for 89 (70%) of the 128 incidents reporting death or severe harm. Five controlled drugs (morphine, diamorphine, fentanyl, midazolam and oxycodone) were responsible for 113 (88%) of these 128 incidents.’

Non-opioid medicines in long-term pain

Patients can be prescribed gabapentin or pregabalin for certain types of pain. Both of these medicines can lead to dependence and may be misused or diverted.

#jargonbuster ‘diverted’ = passed on or sold one to someone else.

Finally, emotional influences are real:

When assessing pain with someone it’s vital that clinicians take all aspects of the person’s life into account, including lifestyle, nutrition, hydration, social and housing factors, safeguarding, sleep and rest, other illnesses, emotional influences and their mental health.

And take a full history of medicines being taken, or recently stopped, including over the counter medicines, internet bought medicines, borrowed medicines and illicit substances.

In this blog Steve Turner, MD of Care Right Now CIC looks at three key areas related to the use of medicines, taken from the NICE Key Therapeutic Topics (2017).

Notes on three key areas:

In this blog I look at three of the NICE Key Therapeutic Topics (2017). This is a 127 page document 127 page document packed with useful information on ‘medicines optimisation’, that’s making the best use of medicines, or ‘getting the medicines right’

#jargonbuster – Here’s my definition of Medicines Optimisation:

‘Medicines Optimisation is all about giving people the option to take the lead in finding ways get the best from their medicines. This includes the option not take medicines and to use alternative approaches. It involves regularly evaluating the situation. Allowing individuals to balance the risks and benefits based on trusted information.’

This is my personal definition. I welcome your views on it.

In the next three sections I look at three of the fifteen key therapeutic topics, give the document and page numbers, and very briefly summarise my take on them.

Of course this is no substitute for reading the full document. This is just to whet your appetite.

1. Multi-morbidity and polypharmacy (that’s taking four or more medicines)

People with multiple illnesses are often prescribed multiple medicines, with new medicines being added to counter side-effects of others. The actual benefits of doing this are hard to ascertain.

Taking multiple medicines involves increased risks.

Everyone with multiple illnesses should receive a holistic person-centred review of their medicines and share in the decision making of what they take. (My view takes this further. I’d say ‘be given the option to lead on the decision making of what they take’).

Polypharmacy (taking four or more medicines) can be divided into two categories. Appropriate polypharmacy, where the benefits and disadvantages have been fully evaluated together. Problematic polypharmacy, where this hasn’t been done and the benefits of the medicines are not realised, sometimes to the extent that they are making the person worse.

There are some useful tools which can be used to help evaluate appropriateness of medicines in individuals (described in the document). Additionally I’d add that motivational interviewing techniques and time to build trust of the patients are also vital.

Intentional non-adherence can be overcome in a trusting clinician patient relationship, which usually happens over time.

#jargonbuster ‘intentional non-adherence’ = not telling clinical staff what you are actually taking and/or not taking.

2. Long term pain

Key Therapeutic Topics pages 27 -33. This section contains a huge amount of information, including links to numerous other documents, on an area critical to patient safety.

Patient safety incidents relating to the unsafe doses of opiates remain a major concern. People develop a ‘tolerance’ to opiate medicines, meaning that higher and higher doses may be needed to deliver the same effect. However this tolerance rapidly goes away when the opiates are stopped, so restarting at the old dose may be fatal.

‘A review of medicines-related safety incidents involving controlled drugs reported to the NRLS over 7 years found the risk of death with controlled drug incidents was significantly greater than with medication incidents generally (odds ratio 1.48, 95% CI 1.02 to 2.17). Incidents involving overdose of controlled drugs accounted for 89 (70%) of the 128 incidents reporting death or severe harm. Five controlled drugs (morphine, diamorphine, fentanyl, midazolam and oxycodone) were responsible for 113 (88%) of these 128 incidents.’

Non-opioid medicines in long-term pain

Patients can be prescribed gabapentin or pregabalin for certain types of pain. Both of these medicines can lead to dependence and may be misused or diverted.

#jargonbuster ‘diverted’ = passed on or sold one to someone else.

Finally, emotional influences are real

When assessing pain with someone it’s vital that clinicians take all aspects of the person’s life into account, including lifestyle, nutrition, hydration, social and housing factors, safeguarding, sleep and rest, other illnesses, emotional influences and their mental health.

And take a full history of medicines being taken, or recently stopped, including over the counter medicines, internet bought medicines, borrowed medicines and illicit substances.

In part one of this two part blog I suggested that patients themselves need to take more responsibility for the medicines they are prescribed.

But what about vulnerable groups who may depend on decisions being made for them, and in their best interests?

Click on the image to enlarge it.

Key points:

Facts:

Most of the prescribing in this area is ‘off label’ ( #jargonbuster – that’s medicines prescribed for something that isn’t listed as an ‘indication’ for that medicine ).

This prescribing can include multiple psychotropic medicines, often medicines in the same class and without relevant indications. There is no evidence base for this type of prescribing.

( #jargonbuster – psychotropic medicines = The phrase “psychotropic drugs” is a technical term for psychiatric medicines that alter chemical levels in the brain which impact mood and behaviour.)

Psychotropic medicines in people with learning disabilities whose behaviour challenges are not always prescribed by a specialist in this area.

Actions to take:

A Holistic assessment.

Before prescribing it’s important to understand all triggers and environmental factors. Reasons for behaviour now and what has happened in the past.

Specialist initiation and review of prescribing.

Multi-Disciplinary team involvement.

Best interests decisions, regularly reviewed.

A tiered approach to prescribing – ‘start low, go slow’.

Involvement of Second Opinion Appointed Doctors (SOADs) to provide a statutory safeguard where consent is an issue.

‘SOADs visit the person and explore the current and proposed treatment, certifying what is considered to be appropriate and reasonable in circumstances where the person cannot or does not consent to it, discussing it with team members and the person before reaching their conclusions.’

Clear documentation:

Of the holistic assessment

Of patient involvement

Of carer and family involvement

Of multi-disciplinary team involvement

Of the rationale for prescribing / not prescribing

Review dates and evidence of reviews

Monitoring of the effect of the medicine(s) that includes as required ‘prn’ medicines (Charts can be useful)

Evidence of changes in response to the medicine(s) not being as expected, including if the medicines has no effect, and the actions taken on this.